From a paper-based to an electronic registry in physiotherapy.
During the past decade the healthcare industry has evolved from paper-based storage of clinical data into the digital era. Electronic healthcare records play a crucial role to meet the growing need for integrated data-storage and data communication. In this context a new law was issued in Belgium on December 7th, 2005, which requires physiotherapists (but also nurses and speech therapists) to keep an electronic version of the registry. This (electronic) registry contains all physiotherapeutic acts, starting from January 1, 2007. Up until that day, a paper version of the registry had to be created every month.This article describes the development of an electronic version of the registry that not only meets all legal constraints, but also enables to verify the traceability and inalterability of the generated documents, by means of SHA-256 codes. One of the major concerns of the process was that the rationale behind the electronic registry would conform well to the common practice of the physiotherapist. Therefore we opted for a periodic recording of a standardized "image" of the controllable data, in the patient database of the software-system, into the XML registry messages. The proposed XSLT schema can also form a basis for the development of tools that can be used by the controlling authorities. Hopefully the electronic registry for physiotherapists will be a first step towards the future development of a fully integrated electronic physiotherapy record.By means of a certification procedure for the software systems, we succeeded in developing a user friendly system that enables end-users that use a quality labeled software package, to automatically produce all the legally necessary documents concerning the registry. Moreover, we hope that this development will be an incentive for non-users to start working in an electronic way.
Buyl
Ronald
R
Department of Biostatistics and Medical Informatics, Faculty of Medicine, Vrije Universiteit Brussel, Belgium. rbuyl@vub.ac.be
Nyssen
Marc
M
D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D016494:Computer Security; D003628:Database Management Systems / Q000458:organization & administration; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D026761:Physical Therapy Specialty / Q000458:organization & administration*; D011787:Quality of Health Care